We need to think about what is best for the patient and then cost, which is what TOHETI has slowly achieved. (…) The approach is not let’s change the pathway, rather let’s see if changing the pathway makes a difference. (Fieldnotes TOHETI Evaluation Meeting).
02 August 2019
TOHETI – programme achievements and personal reflections
Dr Maria Kordowicz, Quality Improvement Research Fellow
As an ambitious imaging programme comes to a close, Dr Maria Kordowicz shares the outcomes and her reflections.
launched in 2014, the TOHETI Programme (Transforming Outcomes and Health Economics through Imaging) had an ambitious vision – to transform imaging pathways, ways of working and be at the forefront of new technologies.
The £10m programme was funded by Guy’s and St Thomas’ Charity and led to the provision of some of the world’s most advanced imaging technologies at Guy’s and St Thomas’ NHS Foundation Trust.
As the five-year programme nears its end, here is a selection of just some of its achievements:
- Winning the ‘Obstetrics and gynaecology’ category in the Health Service Journal (HSJ) Value in Healthcare Awards for significant improvements made in the quality of information available to women who have uterine fibroids
- Improvements made in clinical and administrative processes through collaboration with Siemens and the roll-out of Rapid Improvement Events in CLIMP (Clinical Imaging and Medical Physics Directorate)
- TOHETI used as an exemplar working with the All-Party Parliamentary Group (APPG) on Women’s Health, led by MP Paula Sheriff. TOHETI learning was used to contribute to an enquiry into the informed choice for women in healthcare decisions, with TOHETI pathway patients submitting their stories and experiences
- Strong evidence of egalitarian leadership and a person-centred approach to pathway re-design found by King’s College London evaluation of the organisational processes surrounding TOHETI
- The quicker and higher proportion of fractures being diagnosed due to a study confirming that MRI is associated with higher accuracy levels than x-ray when assessing scaphoid (wrist bone) fractures. Further, the use of immediate wrist Magnetic Resonance Imaging (MRI) in the acute setting leads to lower mean average diagnostic and total costs in the management of suspected scaphoid fractures. These findings could have a significant impact on the wider health economy
- Increasing early detection of colon cancer, improving outcomes and delivering cost-saving benefits by using the increased capacity delivered by the TOHETI funded computerised tomography (CT) scanner. TOHETI aimed to assess whether a change in the current diagnostic pathway, through providing a less invasive diagnostic procedure for colon cancer by replacing optical colonoscopy with CT colonography as the first-line test for symptomatic patients could deliver better outcomes
- Exploring the views of general practitioners and pharmacists about referring to TOHETI’s early lung cancer screening programme, with the aim of improved information provision to healthcare providers and of overcoming any barriers to referral.
I was a member of the TOHETI qualitative evaluation team at the School of Population Health and Environmental Sciences, King’s College London.
We used an ethnographic approach to evaluate the implementation of the TOHETI programme within the Guy’s and St Thomas’ Clinical Imaging and Medical Physics Directorate (CLIMP) and beyond.
This meant, that much like anthropologists, we embedded ourselves in our field of study, having the privilege of observing and interviewing TOHETI stakeholders over a three-year period.
Our report was disseminated to the TOHETI team and Guy’s and St Thomas Charity, who funded the TOHETI programme.
The ethnographic method allowed us to ‘get under the skin’ of the organisational dynamics and the processes of implementing a transformation programme of this scale and ambition.
Key evaluation findings included:
TOHETI as a cultural catalyst
We concluded that the TOHETI programme was a powerful driver of change not only within CLIMP but within Guy’s and St Thomas’ NHS Foundation Trust more broadly, creating a culture of quality improvement and openness to change for patient benefit.
Further, TOHETI has acted as a precursor for large-scale quality improvement at Guy’s and St Thomas’ NHS Foundation Trust in the shape of Care Redesign.
These insights stem from us being able to observe 180 meetings and carrying out 70 interviews with 56 staff members, in addition to the TOHETI teams being open to being evaluated. We were very privileged to have such a volume of data to analyse and the time to do it in – receiving funding for ethnographic studies of this scale and breadth is rare, and yet they often yield rich findings which lie beyond metrics.
Role of research
As TOHETI was an ambitious programme which is based on generating clinical and health economic evidence through several large-scale research studies, initially setting up studies took time and much resource. Over time, it was observed that research brought teams closer together in terms of their aims for improving patient care and making sure that these were rooted in high-quality evidence.
There was a real desire that the new imaging pathways would hold patient experience and quality of care at the centre:
Charity funding was primarily used to fund state-of-the-art machines. These were transformative to ways of working and patient care. This also led to collaborations with Siemens not only around developing the latest diagnostic and interventional approaches but also in service improvements and quality of care delivery.
The programme utilised lean informed management methodologies to transform CLIMP. The evaluation concluded that much time was needed to change ways of working, as well as on-going staff engagement and collaboration.
The programme had strong, egalitarian and developmental leaders at its core. The participants of our study thought that the success of TOHETI rested on this.
Typically, diagnostic pathways cut across several clinical areas. Over time, the evaluation team observed different clinical specialities working better together, with improved communication processes, leading to smoother patient pathways.
The academic team carrying out the evaluation was Dr Mark Ashworth, Dr Patrick White, Professor David Armstrong, Dr Eloise Radcliffe, Dr Guy Shefer and Dr Maria Kordowicz.
For more information see toheti.org and follow us on twitter @TOHETI_Imaging
The King’s Health Partners Imaging and Biomedical Engineering Clinical Academic Group provides comprehensive imaging facilities across one of the largest setups of its kind in Europe.